What is the Chronic Disease Management (CDM) Programme?

A chronic disease is a long-term health condition that needs ongoing treatment and management.

The Structured Chronic Disease Management Programme is for patients who have a medical card and have (or are at
risk) of developing a specific chronic disease: cardiovascular disease, COPD, asthma and type 2 diabetes.

Many of our patients are already registered as CDM Patients and attend twice yearly for their annual reviews.    

The practice will continue to identify any new CDM patients and will invite you to register for the Structured Chronic Disease Management Programme.

The cost of the assessment visits will be covered by your Medical Card or GP Visit card.   
 

CDM Appointment Recall Procedure?

CDM Registered Patients will be issued a SMS (mobile message) to their phone inviting them to book their follow up CDM Appointment (in some cases we may contact patients by phone call or letter invite).

The SMS (or other communication) will state if it is a Nurse or Doctor CDM Consult, pending your CDM condition/CDM Schedule. 

It is very important to act on this invite and book the appropriate appointment to keep your two assessments on schedule.  (Two visits must be completed within a 12 month period of registration date with a minimum of of 4 months apart, otherwise you may miss out on one of your 2 free annual assessment).

For any New CDM Patients

You are eligible to join if you: 

You are eligible to join if you:

• Have a medical card or a GP visit card
• Are you aged over 18 years
• Have a specific chronic disease(s) as listed below
• Can attend your GP surgery

The conditions included in the Chronic Disease Management Programme are:

1. Type 2 Diabetes
2. Asthma
3. Chronic Obstructive Pulmonary Disease (COPD)
4. Cardiovascular Disease including

• Heart failure
• Heart Attack/Angina
• Stroke
• Irregular Heartbeat (Atrial Fibrillation) 

How will I benefit by being part of the Chronic Disease Proogramme?

The Chronic Disease Management programme has been developed in line with international best practice and research. This evidence shows that regular structured reviews of chronic medical conditions leads to improved patient outcomes through better condition management.

The Chronic Disease Management programme can improve your ability to manage your condition and support you by providing:

• Structured reviews of your chronic disease with your GP and practice nurse
• A personalised care plan developed and agreed with your GP
• Regular reviews of your care plan and medication
• Opportunities for structured education and self-management support
• Early detection of any new conditions you may develop
• Early detection of complications in your condition(s)
• Care in your community, close to your home.

How will the programme work for you?

There will be 2 structured reviews in the Surgery each year as part of the Chronic Disease Management Programme.  This amounts to a total of 3-4 visits per year (pending on your CDM Condition).  Each structured review includes 1 visit to your GP and 1 visit to your practice nurse at the Surgery.

How do you book your CDM Appointment? 

Once you are eligible for and confirm your participation, your GP will sign you up to the programme.  You will then be contacted to make an appointment for a structured review directly with the Surgery. You may be required to see the nurse first before your doctors appointments so that the doctor will have your lab results for this consult. 

If you are already registered as a Chronic Disease Management CDM patient and had previous CDM consultations you will be included in our recall system.    Please wait until you receive a reminder invite to your mobile to book your next appointment.